Accident Notification Form

e-form

Form should reach OHSA (email: ohsa@ohsa.mt) within seven (7) days after the accident in terms of LN 52/1986 Article 22.2(b)

Employer's Name

ID Card No.

Company Name

Company Registration No.
(MFSA Reg. No.)

Postal Address

Type of Industry

Email

Telephone

Date of Accident

No. of Persons involved

Place /
Address of Accident

Days out of Work (working days)

Person filing the Accident Notification

Name and Surname

Position within the Company

Signature

Details of Injured Person(s)

Name and Surname

ID Card No.

Gender

Address

Age

Job Title

Name and Surname

ID Card No.

Gender

Address

Age

Job Title

Name and Surname

ID Card No.

Gender

Address

Age

Job Title

Name and Surname

ID Card No.

Gender

Address

Age

Job Title

Type of Accident

Hit by a moving, flying or falling object

Use of Hand Tools

Fall on Same Level

Injured while handling, lifting or carrying

Fall on Lower Level

Injured while using means of transport

Inhaling of fumes/gases

Physically injured after being assaulted by human or animal

Burn

Use of chemicals

Electrocuted

Striking against object

Other (specify)

Type of Injury

Fracture

Laceration with wound

Sprain

Burn

Strain

Chemical Burn

Contusion

Amputation

Other (specify)

Part of Body injured

Hand(s)

Back

Leg(s)

Face

Head

Eye(s)

Forearm(s)

Foot (Feet)

Other (specify)